Provider Demographics
NPI:1629056692
Name:REZAEE, MEHRDAD (MD PHD)
Entity Type:Individual
Prefix:
First Name:MEHRDAD
Middle Name:
Last Name:REZAEE
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 FOREST AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4833
Mailing Address - Country:US
Mailing Address - Phone:408-295-2257
Mailing Address - Fax:408-295-2264
Practice Address - Street 1:2030 FOREST AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4833
Practice Address - Country:US
Practice Address - Phone:408-295-2257
Practice Address - Fax:408-295-2264
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83930207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
G38451Medicare UPIN
00G839300Medicare ID - Type Unspecified